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Based on observation, the facility failed to maintain the fire resistive properties of a two-hour barrier in accordance with NFPA 101, 2012 Edition, Section 19.1.3.3.

Findings include:

1. During an observation on 7/12/2023 at 9:50 a.m., the two-hour wall between the hospital and kitchen/laundry/county offices was inspected. There were three IT wires punched through the two-hour barrier above the double doors. The penetration was not sealed with fire-resistive caulk.

Based on observations, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Sections 7.1.10.1, and 19.2.3.4(1).

Findings include:

1. During an observation on 7/12/2023 at 9:15 a.m., the marked east exit at the end of the corridor was inspected. There was an electric scooter being stored in the exit vestibule reducing the egress width in the vestibule.

2. During an observation on 7/12/2023 at 10:36 a.m., the corridor to the newly built covid testing room was inspected and measured. There was a office copier/printer being stored in the corridor, along with other items. The copier reduced the corridor width to 41", where 44" is the minimum width allowed in an existing corridor.

Based on observation, the facility failed to properly post mandatory signs regarding the function of the delayed egress on the exit doors as required by the code in accordance with NFPA 101, 2012 Edition, Sections 19.2.2.2.4 and 7.2.1.6.

Findings include:

1. During an observation on 7/12/2023 at 9:35 a.m., the dining room patio exit door was inspected. The door was equipped with a delayed egress system which locked the door via magnetic lock. There were no signs posted on the door instructing occupants on the use of the delayed egress locking system.

Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8).

Findings include:

1. During an observation on 7/12/2023 at 10:04 a.m., the main entrance was inspected. There was an ABHR dispenser mounted over a receptacle in the area.

Based on record review and interview, the facility failed to maintain the sprinkler system in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 14.2.

Findings include:

1. Review of facility documentation, and observation, reflected the five-year internal inspection had not been completed. In an interview on 7/12/2023 at 8:00 a.m., staff member A stated the vendor needs to do some upgrades on the dry system to where the system would pass the five year inspection.

Based on observation, the facility failed to provide metal containers with a self closing cover into which ashtrays could be emptied where residents smoked, in accordance with NFPA 101, 2012 Edition, Section 19.7.4.(6).

Findings include:

1. During an observation on 7/12/2023 at 10:00 a.m., the smoking area was inspected. The area did not have a metal container with a self-closing lid for the disposal of trash. There was only one of the tall, cigarette butt disposal cans.

Based on record review, the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 7.2.1.15.1, 4.6.12 and in accordance with NFPA 80-2010, Section 5.2 (written report).

This deficiency affects all smoke compartments.

Findings include:

1. Review of the fire safety maintenance records on 7/12/2023, reflected the lack of the annual fire door assembly testing documentation. The facility must identify the required fire/smoke barriers, as well as electronically controlled doors and doors with special locking arrangement in the building and show inspections of all components of the doors in those barriers.

Based on record review, the facility failed to maintain the receptacles in patient areas.

Findings include:

Record review on 7/12/2023 revealed non-hospital grade receptacles located in resident care rooms throughout the facility did not have annual retention testing as required by sections 6.3.4.1.2 and 6.3.4.1.3 in NFPA 99, Health Care Facilities Code, 2012 Edition.

Actual NFPA Standard: NFPA 99 (2012), 6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).